Tzu Chi Medical Journal 26 (2014) 91e93
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Tzu Chi Medical Journal
journal homepage: www.tzuchimedjnl.com
Case Report
Mediastinal cavernous hemangioma
Kun-Eng Lim a, b, c, *, Jonk-Kai Hsio a, b, Yuan-Yu Hsu a, b, c, Chung-Tai Yue b, Hsu-Chao Chang a,
Chun-Yao Huan d
a
Department of Medical Imaging, Buddhist Tzu Chi General Hospital, Taipei Branch, New Taipei City, Taiwan
School of Medicine, Tzu Chi University, Hulien, Taiwan
c
Tzu Chi College of Technology, Hulien, Taiwan
d
Department of Pulmonary Medicine, Buddhist Tzu Chi General Hospital, Taipei Branch, New Taipei City, Taiwan
b
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 15 November 2012
Received in revised form
24 December 2012
Accepted 7 January 2013
We present a rare case of cavernous hemangioma located in the anterior mediastinum. A 26-year-old
man presented with chest pain and mild dyspnea. Contrast-enhanced computed tomography of the chest
showed a heterogeneous, central enhanced mass in the left side of the anterior mediastinum. A median
sternotomy was performed, which revealed an elastic, firm mass in the anterior mediastinum adhering
to the upper lobe of the left lung. Histopathological examination revealed cavernous hemangioma. The
patient made an uneventful recovery.
Copyright Ó 2013, Buddhist Compassion Relief Tzu Chi Foundation. Published by Elsevier Taiwan LLC. All
rights reserved.
Keywords:
Cavernous hemangioma
Mediastinum
Neoplasm
1. Introduction
Mediastinal hemangiomas are uncommon benign vascular
tumors [1e4]. Mediastinal cavernous hemangiomas can be isolated
or multifocal [5,6]. The preoperative diagnosis of these tumors is
often difficult. We report a symptomatic patient with this tumor in
the anterior mediastinum.
2. Case report
A 26-year-old man presented to the emergency department
with complaints of sudden onset of left side chest pain and mild
dyspnea when he woke up in the morning. The patient’s medical
history was unremarkable. Physical examination and laboratory
data including hematological and biochemical parameters were
within normal limits. A chest radiograph showed a mass in the left
side of the anterior mediastinum and left side pleural effusion.
Noncontrast enhanced computed tomography (CT) scan of the
chest revealed a well-circumscribed ovoid soft-tissue mass, 7.6 cm
in maximal diameter, in the left side of the anterior mediastinum
* Corresponding author. Department of Medical Imaging, Buddhist Tzu Chi
General Hospital, Taipei Branch, 289, Jiauguo Road, Xindian, New Taipei City, Taiwan. Tel.: þ886 2 66289779x1100; fax: þ886 2 25461665.
E-mail address: [email protected] (K.-E. Lim).
and left side pleural effusion (Fig. 1). Contrast-enhanced CT demonstrated heterogeneous, central enhancement within the mass
(Fig. 2). A thoracocentesis was performed under ultrasound guidance and about 5 mL of bloody effusion was obtained. Tumor
markers including alpha-fetoproteins (AFP), b-human chorionic
gonadotropin, lactate dehydrogenase, and carcinoembroyonic
antigen were normal. A percutaneous fine needle aspiration biopsy
of the lesion was performed under CT guidance, but it was not
diagnostic.
The patient underwent a median sternotomy for tumor resection. A 9 cm 8 cm elastic firm tumor in the left side of the
anterior mediastinum with adhesion to the left upper lobe was
noted, but showed no gross invasion of surrounding structures.
About 200 mL of dark reddish pleural effusion was found. The
gross pathological examination showed the resected specimen
measuring 9.5 cm 7.5 cm 5.5 cm and a wedge resection
of the tissue in the upper lobe of the left lung tissue weighed
240 g. On sectioning, a well-defined sponge tumor measuring
8.5 cm 6.0 cm 5.0 cm was seen in the thymus adhering to the
lung tissue. Microscopic examination of the lesion showed irregular thin-walled or thick-walled marked dilated vascular channels
with focal hyalinization fibrosis (Fig. 3). The tumor adhered firmly
to the lung tissue, but there was no definite direct invasion of the
lung. Histopathology of the tumor showed cavernous hemangioma. The patient has been in good condition throughout the 5
months following the operation.
1016-3190/$ e see front matter Copyright Ó 2013, Buddhist Compassion Relief Tzu Chi Foundation. Published by Elsevier Taiwan LLC. All rights reserved.
http://dx.doi.org/10.1016/j.tcmj.2013.01.009
92
K.-E. Lim et al. / Tzu Chi Medical Journal 26 (2014) 91e93
Fig. 1. Unenhanced CT scan shows a soft-tissue mass without calcifications in the
anterior mediastinum and a left side pleural effusion.
3. Discussion
Mediastinal hemangiomas are uncommon benign vascular
tumors that account for approximately 0.5% of all mediastinal
tumors [1e4]. The tumors are frequently located in the anterior
mediastinum, with only a few located in the middle or posterior
mediastinum.
Mediastinal hemangiomas usually occur in young patients, and
approximately 75% of these lesions manifest before the age of 35
years [1]. Males and females are affected with equal frequency [1,7].
Most patients are asymptomatic at presentation and diagnoses are
made incidentally with imaging. Patients may present with nonspecific symptoms including cough, chest pain, dyspnea, stridor,
and hoarseness due to the mass effect of the tumor on adjacent
organs.
Mediastinal hemangiomas are grossly well circumscribed and
unencapsulated, ranging from 2 cm to 20 cm [8]. They are histologically classified into cavernous, capillary, and venous types
based on the size of their vascular spaces. More than 90% are
capillary or cavernous hemangiomas. Venous hemangiomas are
extremely rare. Capillary hemangiomas are characterized by a
lobular, solid growth pattern featuring dilated small vessels and a
solid proliferation of endothelial cells [8]. Cavernous hemangiomas
are characterized by large, dilated vascular spaces interposed with
various stromal elements such as fat, mxyoid fibroblastic proliferation, and fibrous tissue [8]. Cavernous hemangiomas do not
spontaneously regress, unlike their capillary counterparts.
Fig. 3. A histological section of the tumor shows blood vessels of different calibers
(hematoxylineeosin stain, magnification 40).
The preoperative diagnosis of a mediastinal hemangioma with
conventional radiography is difficult as the lesion usually presents
as a nonspecific mass [4]. Focal phleboliths are seen in approximately 10% of cases, but when present, are a diagnostic sign of
hemangioma [1,3,4,7,9,10]. Phleboliths were not observed in our
patient. On unenhanced CT scans, hemangiomas are usually wellcircumscribed, heterogeneous soft-tissue masses. Their appearance depends on the stromal content and degree of thrombosed
vascular channels [11]. On contrast-enhanced CT scans, the tumors
usually enhance heterogeneously and centrally as depicted in our
patient [4,9]. Peripheral enhancement and puddling of contrast
medium peripheral to the mass has been reported on enhanced CT
scans [4,12]. Gradually increasing, persistent enhancement has
been reported on dynamic contrast enhanced CT scans, suggesting
this technique can provide valuable information for preoperative
planning [13]. On magnetic resonance (MR) imaging, hemangiomas
appear homogeneous or heterogeneous, and are hypointense on
T1-weighted images and hyperintense on T2-weighted images
[10,12,14]. The MR appearance is not specific for this type of tumor,
as other masses can appear similar.
In conclusion, cavernous hemangioma is an extremely rare
benign vascular tumor of the mediastinum. The preoperative
diagnosis of this lesion is often difficult. Hemangioma must be
considered in the differential diagnosis of anterior mediastinal
tumors when phleboliths and heterogeneous enhancement within
the mass are seen on CT. CT or MR imaging can provide useful
information on the location and invasiveness of the tumor.
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Fig. 2. Contrast enhanced CT scan shows heterogeneous, central enhancement within
the mass.
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